Things Nurses Can/Must Do to Improve Relations with Physicians

The other day a reporter from Nurse Zone called me to tell me she was doing a story on things nurses can do to improve relations with physicians.  Her name is Jennifer Larson and she is committed to the issue, which is great.  When we discussed the issue, she mentioned the idea that nurses could be physician whisperers, kind of like horse whisperers who calm down skittish horses.  I pointed out that the very idea of a”physician whisperer” is a total replication of the age old nurse doctor game which Leonard Stein wrote about several decades ago.  rain which nurses placate or otherwise indirectly manage physicians rather than dealing with them in a respectful but assertive manner.  Larson wrote a very good article about dealing with physicians but I would add quite a bit more.  In fact, I believe we have to get rid of the traditional and very outdated and dysfunctional “secrets” or “secret of managing” doctors, aides, or anyone else  mentality. Nurses as well as any other staff that have been in a traditionally deferential or subordinate relationship to higher status players  have to take advantage of the opportunities presented by the movement to enhance patient safety and encourage interprofessional practice and develop the capacity and skills to deal with people in a direct, respectful but assertive manner.  Rather than being so obsessed with leadership, nurses have to develop a concept of assertive team membership and learn the skills that have been utilized in aviation and other high reliability industries so that they can become true and full members of the health care team.  The way to do this is to mobilize IAA — Inquiry, Advocacy and Assertion.

So here are my Seven Non-Secrets to more Effective Team Relationships, particularly when nurses or others are dealing with traditional high status players like physicians.

Step One — Never Apologize!!! Ever.  As RN Paulina Bleah has written in an essay in a soon to be published book I have written with physician patient safety advocates David L. Feldman and Michael Leonard called Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, nurses typically apologize to physicians when they ask them to do their jobs.  A nurse calls a doc in the middle of the night, or anytime and begins with an abject apology (i.e. “oh Dr. Smith, I am so sorry to bother you), asks a question and then ends with an abject apology as if Dr. Smith has amnesia and didn’t get it the first time.  Don’t apologize to anyone for asking them to do their job.  Would you apologize to your lawyer for calling them and giving them a case or asking for advice?  I wouldn’t since those nine of ten words and seconds of the apology would have cost me $20 bucks or more.

Step Two — Enter the Circle of Care.  Don’t Position Yourself in the Outfield!! How many times have you seen the following?  A group of physicians is talking together, or there is a supposedly interprofessional rounds going on.  The physicians are standing in a circle.  An RN comes up to them to talk about a serious clinical issue.  She/he positions herself/himself outside the circle.  No one invites her/him in. She/he does not move in.  Or consider this “interprofessional rounds” that I described in my essays on Teams and Team Intelligence in First Do Less Harm. The “team” included an attending physician, a pharmacist, and two nurses – the bedside RNs caring for the patient the group would be discussing. As Dr. S discussed a series of patients, she stood with her back to the two nurses and addressed the residents and med students. For the next 15 minutes her stance never altered. She never turned to include them in the conversation. The two bedside nurses stood on tiptoe or craned their necks in an effort to hear what the doctor was saying to the residents and medical students. The two nurses never moved next to the wall even though there was plenty of room there.  If you are in this situation, which many nurses confront every day, move into the circle, be part of the team.  Do not place yourself on the outside.

Step Three – If You Are Invited to the Table Sit at the Table .  In a previous blogpost I described a situation in which nurses and other non-MD professionals are attending interprofessional team meetings.  Rather than sit at any seats at the conference table in the center of the room, nurses place themselves at the periphery, in the chairs on the outside of the room, even though there are empty chairs at the table.  They do this, I am told, because those chairs are “reserved” for physicians and administrators.  Who reserved them?  No one really.  So help create real interprofessional practice.  Sit at the table.

Step Four – If You are Invited to the Table, Speak.  How many times have I sat in a meeting to which nurses were invited and yet they said nothing.  This is not just a phenomenon I have observed with bedside nurses.  I have watched PhD RNs sit silently or speak only about narrow nursing issues when I know they have lots to say about broader systems issues.  (Nurses claim after all that they are the ones who are holistic and have a broad understanding of health care system problems) I understand the nervousness people feel when they are in a mixed group, particularly one with high status players.  So if you are going into such a meeting, role play it, practice, rehearse but speak up.  If you don’t pretty soon people will wonder why they bothered inviting you and you will be either disinvited or further dis-regarded.  Remember, silence speaks volumes.

Step Five – Insist on Equal Naming Practices.  Nurses –even older nurses – constantly allow themselves to be called by their first name while they call physicians –even young ones – with title and last name.  As in Dr. Smith, this is Suzy.  This form of naming practice, unknown in the outside world where first names are now routine – delivers a very specific message about status.  Nurses are not important, physicians are.  Nurses not only allow this practice but reinforce it.  Nurses who are on a first name basis with physicians typically change this practice when in front of patients.  The physician they referred to by first name only suddenly becomes Dr. Smith when in the presence of a patient.  When I ask nurses why they do this, they insist that it’s important for the patient to respect their physician.  Like a mother in front of a child, they are telling the patient that they must respect their daddy.  This not only serves to put the nurse in a one down position, it tells the patient that they must be deferential to the doctor. Don’t nurses deserve respect?  And if respect resides in the last name and title, why don’t they insist on being called Nurse Smith?  And how can they allow physicians to call patients by their first names if they insist the patient call the physician with last name and title?   How can nurses claim to be patient advocates, if they are advocating for this paternalistic definition of the authority of the physician?  This practice should end.  To see how to do that please read what Bernice Buresh and I have to say about this in our book From Silence to Voice.

Step Six – Understand the Difference Between Respect and Reverence.  Healthcare is totally confused about the difference between respect and reverence.

Webster’s Dictionary defines respect thusly, “a feeling or understanding that someone or something is important, serious, etc., and should be treated in an appropriate way.” http://www.merriam-webster.com/dictionary/respect?show=0&t=1405269538

Reverence on the other hand is defined as ”profound adoring awed respect.”  Reverence is the attitude religious people feel toward God, or priests.  Is this the way we want to view physicians?  How can people intervene to appropriately challenge a physician, administrator, chief nurse, whomever, if we hold them in awe?”

Step Seven – Learn How to Speak Up.  Nurses have been tutored in silence for centuries.  This kind of tutoring still goes on.  I recently wrote a blogpost about a student nurse who said he was “crippled by shame,” because his clinical instructors told him not to point out that attending physicians hadn’t washed their hands. “You don’t want to be considered to be a loud-mouth or know it all,” the instructor told the student.  Nurses need to stop teaching each other how to shut up and need to help each other to learn how to constructively speak up.